A nurse is collecting data from a newborn who was born 24 hrs ago. Which of the following images should the nurse identify as an indication that the newborn has erythema toxicum?

A. "A client must sign an Against Medical Advice form if he withdraws consent.": An Against Medical Advice (AMA) form is specifically used when a client chooses to leave a healthcare facility against medical advice, not when they withdraw consent for a procedure. Withdrawing consent does not require an AMA form and follows a separate legal and ethical process.

B. "A client can withdraw consent at any time after signing the informed consent form.": Clients maintain the right to autonomy throughout their care, including the right to withdraw consent at any point before or during a procedure. Signing the form does not waive their right to change their mind, and healthcare providers must respect this decision without penalizing the client.

C. "A client who is involuntarily admitted to a mental health unit cannot withdraw consent for treatment.": Even clients who are involuntarily admitted retain certain rights, including the right to refuse specific treatments unless they are legally deemed incompetent or pose an imminent threat. Involuntary admission does not mean automatic consent to all treatments.

D. "A client must provide a written refusal for a procedure for which he has already signed an informed consent.": Clients can verbally withdraw consent at any time; a written refusal is not legally required. While documentation of the client's decision is necessary for the medical record, insisting on a written refusal is not a legal prerequisite for withdrawal of consent.

• Lung sounds: The client is exhibiting slight inspiratory wheezes, suggesting airway narrowing that could worsen quickly, particularly with a history of asthma. Following the ABC priority framework (Airway, Breathing, Circulation), any compromise in breathing must be assessed and managed first to prevent respiratory decline.
• Bowel sounds: Although bowel sounds are hyperactive, they do not immediately threaten life or stability. They are typically monitored rather than prioritized unless accompanied by severe gastrointestinal symptoms like obstruction.
• Heart rate: Tachycardia is present but mild at 104/min and not currently associated with hypotension or hypoxia. While important to monitor, it is a secondary concern after ensuring airway patency and addressing breathing issues.
• Anxiety: Anxiety may be contributing to elevated heart rate and hyperactive bowel sounds but does not represent an immediate physiological risk. Emotional support is important but should be provided after stabilizing airway and circulation.
• Vaginal spotting: Vaginal spotting, especially in early pregnancy with abdominal tenderness, raises concern for ectopic pregnancy. After securing the airway, the next concern would be assessing for ongoing or worsening vaginal bleeding, which could signify internal hemorrhage.
• Hemoglobin: The client's hemoglobin is low-normal (11 g/dL), suggesting mild anemia, possibly from chronic or early bleeding. However, there are no signs of active major blood loss requiring emergent correction, so it would not take immediate precedence over bleeding evaluation.